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psnet.ahrq.gov/issue/disclosure-and-apology-nursing-and-risk-management-working-together
August 21, 2015 - Commentary
Disclosure and apology: nursing and risk management working together.
Citation Text:
Russell D. Disclosure and apology: Nursing and risk management working together. Nurs Manage. 2018;49(6):17-19. doi:10.1097/01.NUMA.0000533773.14544.e2.
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psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
January 22, 2016 - Study
Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases.
Citation Text:
Stone S, Bernstein M. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60(6):1075-80; discussion 1080-2.
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psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection
October 08, 2024 - Press Release/Announcement
Common Formats for Patient Safety Data Collection.
Citation Text:
Common Formats for Patient Safety Data Collection. Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - potential for medical errors.(12)
In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented
with the use of a standardized checklist requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - Although ED physicians felt he had simple bruising from the fall, they noted that he was in severe pain requiring … proportion to the skin manifestations is a consistent feature of NF
In this case, the patient's severe pain requiring
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - This is because the Universal Protocol does not differentiate between types of cases requiring
imaging … For example, a change in hospital policy
requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - The Case
A 74-year-old man had a long history of coronary artery disease requiring coronary artery bypass … occupancy and prioritize elective admissions.(4) Subsequently, during daily surges of ED patients
requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - While waiting for the diagnostic tests, the patient had progressively severe pain, requiring relatively … challenging
There are often weight restrictions for diagnostic tests (e.g., CT scanning)
Abdominal processes requiring
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - The patient
had a stormy postoperative course, complicated by aspiration pneumonia requiring intubation … more than 1500 such patients, only a tiny minority (0.2%) went on to develop clinical
appendicitis requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - transcription step that led to the wrong sodium concentration being entered into the computer
Without CPOE, requiring … checked the PN label against original order
*
*
Take-Home Points
PN is a high-alert medication requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring